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An acute bacterial infection of the dermis and subcutaneous tissue
Types and locations:
Periorbital cellulitis: bacterial infection of the eyelid and surrounding tissues (anterior compartment)
Orbital cellulitis: Infection of the eye posterior to the septum; sinusitis is the most common risk factor.
Facial cellulitis: preceded by upper respiratory infection or otitis media
Buccal cellulitis: infection of cheek in children associated with bacteremia (common before Haemophilus influenzae type B vaccine)
Peritonsillar cellulitis: common in children associated with fever, sore throat, and “hot potato” speech
Abdominal wall cellulitis: common in morbidly obese patients
Perianal cellulitis: sharply demarcated, bright, perianal erythema
Necrotizing cellulitis: gas-producing bacteria in the lower extremities; common in diabetics
System(s) affected: skin/exocrine
Predominant sex: male = female (common in elderly and adults, except perianal cellulitis which is common in children)
All-cause mortality for patient admitted with cellulitis is 7%. Recurrence rate of cellulitis is 8–20% (1)[A].
β-Hemolytic streptococci (groups A, B, C, G, and F), S. aureus, including MRSA and gram-negative aerobic bacilli, are the most common.
S. aureus: periorbital and orbital cellulitis and IV drug users
Pseudomonas aeruginosa: diabetics and other immunocompromised patients
Aeromonas hydrophila and Vibrio vulnificus: cellulitis caused by waterborne pathogens
H. influenzae: buccal cellulitis
Clostridia and non–spore-forming anaerobes: necrotizing cellulitis (crepitant/gangrenous)
Streptococcus agalactiae: cellulitis following lymph node dissection
Pasteurella multocida and Capnocytophaga canimorsus: cellulitis preceded by bites
Streptococcus iniae: immunocompromised hosts
Rare causes: Mycobacterium, fungal (mucormycosis, aspergillosis, syphilis)
Disruption of skin barrier: trauma, infection, insect bites, injection drug use, body piercing
Inflammation: eczema or radiation therapy
Edema due to venous insufficiency. Lymphatic obstruction due to surgical procedures or congestive heart failure
Elderly, diabetes, hypertension, obesity
Cellulitis recurrence score (2)[A]
Recurrent cellulitis is seen in immunocompromised patients (HIV/AIDS, steroids and TNF-α inhibitor therapy, diabetes, hypertension, cancer, peripheral arterial or venous diseases, chronic kidney disease, dialysis, IV or SC drug use (2)[A].
Good skin hygiene
Support stockings to decrease edema
Maintain tight glycemic control and proper foot care in diabetic patients.
Previous trauma, surgery, animal/human bites, dermatitis, fungal infection; all serve as a portal of entry for bacterial pathogens.
Pain, itching, and/or burning
Fever, chills, and malaise
Localized pain and tenderness with erythema, induration, swelling, and warmth
Peau d’orange appearance
Purulent drainage (from abscesses)
Orbital cellulitis: proptosis, globe displacement, limitation of ocular movements, vision loss, diplopia
Facial cellulitis: malaise, anorexia, vomiting, pruritus, burning, anterior neck swelling
If there are signs of systemic disease (fever, heart rate >100 bpm, or systolic blood pressure <90 mm Hg): blood cultures, CPK, CRP. Consider serum lactate levels.
WBC has 84% specificity and 43% sensitivity; whereas CRP had a sensitivity of 67% and specificity of 95% (PPV 95% and NPV 68%).
Aspirates from point of maximum inflammation yield 45% positive culture compared with 5% from leading edge
Blood cultures: Pathogens are isolated in <5% of patients. Blood cultures in children are more likely to show a contaminant than true positive.
Swab open cellulitis wounds for culture.
Plain radiographs, CT, or MRI are useful if osteomyelitis, fracture, necrotizing fasciitis, or retained foreign body is suspected or underlying abscess.
Gallium67 scintillography helps detect cellulitis superimposed on chronic limb lymphedema.
Immobilize and elevate the involved limb to reduce swelling.
Sterile saline dressings or cool aluminum acetate compresses for pain relief
Edema: compression stocking, pneumatic pumps. Diuretic therapy for CHF patients
Mark the area of cellulitis to monitor progression.
Tetanus immunization if needed, particularly if there is an open (traumatic) wound
Target treatment in the setting of known pathogens or certain exposure (animal bites)
Antibiotic selection relies on clinical presentation:
With nonpurulent drainage, target treatment toward β-hemolytic streptococci and MSSA.
Outpatient: treatment duration of 5 to 10 days
Oral: for mild cellulitis
Cephalexin 500 mg PO q6h; children: 25 to 50 mg/kg/day in 3 to 4 doses
Dicloxacillin 500 mg PO q6h; children: 25 to 50 mg/kg/day in 4 doses
Clindamycin 300 to 450 mg PO q6–8h; children: 20 to 30 mg/kg/day in 4 doses
IV: for rapidly progressing cellulitis
Cefazolin 1 to 2 g IV q8h; children: 100 mg/kg/day IV in 2 to 4 divided doses
Oxacillin 2 g IV q4h; children: 150 to 200 mg/kg/day IV in 4 to 6 doses
Nafcillin 2 g IV q4h; children: 150 to 200 mg/kg/day IV in 4 to 6 doses
Clindamycin 600 to 900 mg IV q8h; children: 25 to 40 mg/kg/day IV in 3 to 4 doses
Purulent cellulitis (probable CA-MRSA)
Culture all purulent wounds and follow up in 48 hours.
Incise and drain abscess and start empiric antibiotic therapy. Modify based on culture results; tailor duration based on clinical response (3)[B]:
Clindamycin 300 to 450 mg PO; children: 40 mg/kg/day in 3 to 4 doses
Trimethoprim-sulfamethoxazole (TMP-SMZ) 1 DS tab PO BID; children: dose based on TMP at 8 to 12 mg/kg/day divided in 2 doses
Doxycycline 100 mg PO BID; children >8 years of age: ≤45 kg: 4 mg/kg/day divided in 2 doses; >45 kg: 100 mg PO BID
Minocycline 200 mg PO once, then 100 mg PO BID; children >8 years old: 4 mg/kg PO once, then 4 mg/kg PO BID
Linezolid 600 mg PO BID; children <12 years: 10 mg/kg/dose (max 600 mg/dose) PO TID; ≥12 years: 600 mg PO BID
Tedizolid 200 mg PO once daily; children: Dosing is not established.
Vancomycin 15 to 20 mg/kg/dose IV every 8 to 12 hours
Daptomycin 4 mg/kg/dose IV once daily; if bacteremia is present or suspected: 6 mg/kg IV once daily
Linezolid 600 mg IV BID
Tedizolid 200 mg IV once daily
Ceftaroline 600 mg IV q12h
Tigecycline 100 mg IV once, thereafter 50 mg IV q12h
Necrotizing cellulitis: requires broad-spectrum coverage to cover clostridial and anaerobic species: ampicillin-sulbactam 1.5 to 3.0 g q6–8h IV or piperacillin-tazobactam 3.37 g q6–8h IV plus ciprofloxacin 400 mg q12h IV plus clindamycin 600 to 900 mg q8h IV
Freshwater exposure: penicillinase-resistant: penicillin plus gentamicin or fluoroquinolone; in salt water exposure: doxycycline 200 mg IV in 2 divided doses
Bites: The combination of amoxicillin and clavulanic acid is recommended for human and dog bites. Ticarcillin and clavulanic acid or the combination of a 3rd-generation cephalosporin (i.e., ceftriaxone) plus metronidazole provides adequate parenteral therapy for animal or human bites. If allergic to penicillin, use fluoroquinolone plus metronidazole.
Facial cellulitis in adults: ceftriaxone IV
Diabetic foot infection: ampicillin/sulbactam or imipenem/cilastatin or meropenem; alternative: combinations of targeting anaerobes as well as gram-positive and gram-negative aerobes
If severe infection, toxicity, immunocompromised patients, or worsening infection despite empirical therapy, admit for empiric antibiotic therapy covering MRSA.
Recurrent streptococcal cellulitis: penicillin 250 mg BID, or if penicillin-allergic, use erythromycin 250 mg BID
Avoid doxycycline in children ≥8 years old and during pregnancy.
Penicillin allergy: erythromycin 500 mg PO q6h
Cephalexin remains a cost-effective therapy for outpatient management of cellulitis at current estimated MRSA levels.
Débridement for gas and purulent matter
Intubation or tracheotomy may be needed for cellulitis of the head or neck.
Severe infection, suspicion of deeper or rapidly spreading infection, tissue necrosis, or severe pain
Marked systemic toxicity or worsening symptoms that do not resolve after 24 to 48 hours of therapy
Patients with underlying risk factors or severe comorbidities
Repeat relevant labs (blood culture, CBC, potentially LP) if patient is toxic or not improving.
Consider deep vein thrombosis prophylaxis.
Cutaneous inflammation may worsen in the first 24 hours due to release of bacterial antigens. Symptomatic improvement usually occurs in 24 to 48 hours, but visible improvement may take 72 hours.
Low-dose penicillin prophylaxis in patients with recurrent cellulitis decreases recurrence (4)[A].
Local abscess or bacteremia, sepsis
Superinfection with gram-negative organisms
Lymphangitis, especially if recurrent
Thrombophlebitis or venous thrombosis
Brook I. Management of human and animal bite wounds: an overview. Adv Skin Wound Care. 2005;18(4):197–203.
Gunderson CG. Cellulitis: definition, etiology, and clinical features. Am J Med. 2011;124(12):1113–1122.
Kilburn SA, Featherstone P, Higgins B, et al. Interventions for cellulitis and erysipelas. Cochrane Database Syst Rev. 2010;(6):CD004299.
Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):285–292.
Oh CC, Ko HC, Lee HY, et al. Antibiotic prophylaxis for preventing recurrent cellulitis: a systematic review and meta-analysis. J Infect. 2014;69(1):26–34.
Phoenix G, Das S, Joshi M. Diagnosis and management of cellulitis. BMJ. 2012;345:e4955.
Quirke M, O’Sullivan R, McCabe A, et al. Are two penicillins better than one? A systematic review of oral flucloxacillin and penicillin V versus oral flucloxacillin alone for the emergency department treatment of cellulitis. Eur J Emerg Med. 2013;21(3):170–174.
L03.90 Cellulitis, unspecified
H05.019 Cellulitis of unspecified orbit
L03.211 Cellulitis of face
J36 Peritonsillar abscess
H05.012 Cellulitis of left orbit
H05.013 Cellulitis of bilateral orbits
L03.119 Cellulitis of unspecified part of limb
L03.221 Cellulitis of neck
L03.317 Cellulitis of buttock
L03.319 Cellulitis of trunk, unspecified
L03.818 Cellulitis of other sites
H05.011 Cellulitis of right orbit
682.9 Cellulitis and abscess of unspecified sites
376.01 Orbital cellulitis
682.0 Cellulitis and abscess of face
475 Peritonsillar abscess
682.1 Cellulitis and abscess of neck
682.2 Cellulitis and abscess of trunk
682.3 Cellulitis and abscess of upper arm and forearm
682.4 Cellulitis and abscess of hand, except fingers and thumb
682.5 Cellulitis and abscess of buttock
682.6 Cellulitis and abscess of leg, except foot
682.7 Cellulitis and abscess of foot, except toes
682.8 Cellulitis and abscess of other specified sites
128045006 cellulitis (disorder)
109245003 Cellulitis of periorbital region
200652002 cellulitis of face (disorder)
102453009 Peritonsillar cellulitis (disorder)
62837005 Cellulitis of hand
128276007 Cellulitis of foot
13680009 Cellulitis of forearm (disorder)
287001000 Cellulitis of leg, excluding foot (disorder)
37223007 Cellulitis of neck
38217004 Cellulitis of upper arm (disorder)
44428005 Cellulitis of buttock
46876003 Cellulitis of trunk (disorder)
S. aureus and group A Streptococcus are the most common organisms that cause cellulitis.
Consider MRSA if cellulitis is not responding to antibiotics in the first 48 hours.
Rapid expansion of infected area with red/purple discoloration and severe pain may suggest necrotizing fasciitis, requiring urgent surgical evaluation.